Establishment of a post-disaster healthcare information booklet for the Turkey-Syrian earthquake, based on past disasters.

The scientific evidence based on experiences with past disasters points to the possibility of the occurrence of future mental health issues among those who were affected by the recent Turkey-Syria earthquake. However, post-disaster care information on factors that could give rise to mental health issues among those affected have yet to be provided. In March 2011, Tohoku University compiled and published a booklet with post-disaster healthcare information based on the experiences with the Great East Japan Earthquake. This study aimed to promote the introduction and use of this booklet for post-disaster care in Turkey and Syria by presenting the results of a satisfaction survey conducted with relevant Japanese organizations about the booklet. A total of 505 Japanese organizations participated in the satisfaction survey of, and evaluated, the booklet. The results indicated the need to consider the ease of understanding for the general public when providing information on post-disaster care through booklets. We hope that this study leads to the appropriate provision of easy-to-understand, post-disaster healthcare information to the victims of the Turkey-Syria earthquake and future disasters.

Intratumoral cortisol associated with aromatase in the endometrial cancer microenvironment.

Glucocorticoids bind to glucocorticoid receptors (GR). In the peripheral tissues, active cortisol is produced from inactive cortisone by 11ß-hydroxysteroid dehydrogenase (HSD)1. 11ß-HSD2 is responsible for this reverse catalysis. Although GR and 11ß-HSDs have been reported to be involved in the malignant behavior of various cancer types, the concentration of glucocorticoids in cancer tissues has not been investigated. In this study, we measured glucocorticoids in serum and cancer tissues using liquid chromatography-tandem mass spectrometry and clarified, for the first time, the intratumoral "intracrine" production of cortisol by 11ß-HSD1/2 in endometrial cancer. Intratumoral cortisol levels were high in the high-malignancy type and the cancer proliferation marker Ki-67-high group, suggesting that cortisol greatly contributes to the malignant behavior of endometrial cancer. A low expression level of the metabolizing enzyme 11ß-HSD2 is more important than a high expression level of the synthase 11ß-HSD1 for intratumoral cortisol action. Intratumoral cortisol was positively related to the expression/activity of estrogen synthase aromatase, which involved GR expressed in fibroblastic stromal cells but not in cancer cells. Blockade of GR signaling by hormone therapy is expected to benefit patients with endometrial cancer.

Excessive ultraviolet C irradiation causes spore protein denaturation and prohibits the initiation of spore germination in Bacillus subtilis.

Ultraviolet (UV) -C is widely used to kill bacteria as it damages chromosomal DNA. We analyzed the denaturation of the protein function of Bacillus subtilis spores after UV-C irradiation. Almost all of the B. subtilis spores germinated in Luria-Bertani (LB) liquid medium, but the colony-forming unit (CFU) of the spores on LB agar plates decreased to approximately 1/103 by 100 mJ/cm2 of UV-C irradiation. Some of the spores germinated in LB liquid medium under phase-contrast microscopy, but almost no colonies formed on the LB agar plates after 1 J/cm2 of UV-C irradiation. The fluorescence of the green fluorescent protein (GFP) -fused spore proteins, YeeK-GFP, YeeK is a coat protein, decreased following UV-C irradiation of over 1 J/cm2, while that of SspA-GFP, SspA is a core protein, decreased following UV-C irradiation of over 2 J/ cm2, respectively. These results revealed that UV-C affected on coat proteins more than core proteins. We conclude that 25 to 100 mJ/cm2 of UV-C irradiation can cause DNA damage, and more than 1 J/cm2 of UV-C irradiation can cause the denaturation of spore proteins involved in germination. Our study would contribute to improve the technology to detect the bacterial spores, especially after UV sterilization.

Anterior horn damage in brachial multisegmental amyotrophy with superficial siderosis and dural tear: an autopsy case report.

BACKGROUND: Patients with superficial siderosis (SS) rarely show brachial multisegmental amyotrophy with ventral intraspinal fluid collection accompanied with dural tear. CASE PRESENTATION: We describe spinal cord pathology of a 58-year-old man who developed brachial multisegmental amyotrophy with ventral intraspinal fluid collection from the cervical to lumbar spinal levels accompanied with SS, dural tear, and snake-eyes appearance on magnetic resonance imaging (MRI). Radiological and pathological analyses detected diffuse and prominent superficial deposition of hemosiderin in the central nervous system. Snake-eyes appearance on MRI expanded from the C3 to C7 spinal levels without apparent cervical canal stenosis. Pathologically, severe neuronal loss at both anterior horns and intermediate zone was expanded from the upper cervical (C3) to middle thoracic (Th5) spinal gray matter, and these findings were similar to compressive myelopathy. CONCLUSION: Extensive damage of the anterior horns in our patient may be due to dynamic compression induced by ventral intraspinal fluid collection.

Comparative analysis of thioflavin T and other fluorescent dyes for fluorescent staining of Bacillus subtilis vegetative cell, sporulating cell, and mature spore.

Thioflavin T, a cationic benzothiazole dye, is typically used to detect amyloid fibrils. In this study, we analyzed the staining properties of Bacillus subtilis cells using several fluorescent dyes, including thioflavin T analogs, 2-(4'-methylaminophenyl) benzothiazole (BTA-1), and 2-(4-aminophenyl) benzothiazole (APBT). Thioflavin T stained vegetative cells in the early log phase and outer layer structures of forespores and mature spores. The inner parts of forespores and heat-killed mature spores were also stained with thioflavin T. Congo red, auramine O, and rhodamine B stained forespores and mature spores similar to thioflavin T. In contrast, APBT and BTA-1 fluorescence was detected in the outer layers of vegetative cells, mother cells, forespores, and mature spores, indicating that they bind to the cell membrane and/or cell wall. The combination of the fluorescent dyes used in this study will help analyze morphogenetic processes during the sporulation and the damage mechanisms of vegetative cells and spores.

Safety and Validity of Anterior Cervical Disc Replacement for Single-level Cervical Disc Disease: Initial Two-year Follow-up of the Prospective Observational Post-marketing Surveillance Study for Japanese Patients.

Anterior cervical disc replacement (ACDR) using cervical artificial disc (CAD) has the advantage of maintaining the range of motion (ROM) at the surgical level, subsequently reducing the postoperative risk of adjacent disc disease. Following the approval for the clinical use in Japan, a post-marketing surveillance (PMS) study was conducted for two different types of CAD, namely, Mobi-C (metal-on-plastic design) and Prestige LP (metal-on-metal design). The objective of this prospective observational multicenter study was to analyze the first 2-year surgical results of the PMS study of 1-level ACDR in Japan. A total of 54 patients were registered (Mobi-C, n = 24, MC group; Prestige LP, n = 30, PLP group). Preoperative neurological assessment revealed radiculopathy in 31 patients (57.4%) and myelopathy in 15 patients (27.8%). Preoperative radiological assessment classified the disease category as disc herniation in 15 patients (27.8%), osteophyte in 6 patients (11.1%), and both in 33 patients (61.1%). The postoperative follow-up rates at 6 weeks, 6 months, 1 year, and 2 years after ACDR were 92.6%, 87.0%, 83.3%, and 79.6%, respectively. In both groups, patients' neurological condition improved significantly after surgery. Radiographic assessment revealed loss of mobility at the surgical level in 9.5% of patients in the MC group and in 9.1% of patients in the PLP group. No secondary surgeries at the initial surgical level and no serious adverse events were observed in either group. The present results suggest that 1-level ACDR is safe, although medium- to long-term follow-up is mandatory to further verify the validity of ACDR for Japanese patients.

The Study of Diversity in Sporulation among Closely Genetically Related Bacillus cereus Strains.

Bacillus cereus is an important foodborne pathogenic bacterium. Although several B. cereus strains have been isolated from the environment, the differences among these strains with respect to spore formation ability and cell morphology need clarification. In this study, a phylogenetic tree was constructed based on the 16S rRNA gene sequences of nine strains of B. cereus. Spore formation and morphology of these nine strains were compared using both phase-contrast and fluorescence microscopy to create an index of the designated sporulation stages. Additionally, to investigate the efficiency of heat-resistant spore formation. Phylogenetic analysis revealed that five strains (ATCC 14579T, NBRC 3457, NBRC 3514, NBRC 3836, and NBRC 13597) clustered together and the remaining four (ATCC 10987, NBRC 3003, NBRC 13494, and NBRC 13690) were genetically distinct from each other. Phase-contrast microscopy revealed significant differences in the sporulation stages among the nine strains. Furthermore, the efficiency of heat-resistant spore formation also differed, even among genetically related strains. In conclusion, a variety of cell morphologies during sporulation were observed among the nine B. cereus strains. We propose a designation of sporulation stages in B. cereus ATCC 14579T, which may be used as an index for evaluating the sporulation progress of B. cereus.

Supporting adolescents' mental health during COVID-19 by utilising lessons from the aftermath of the Great East Japan Earthquake.

Historical data can determine how adolescents recover from difficult situations such as the Coronavirus disease 2019 (COVID-19) pandemic. This study analysed 3 years of data obtained from high-school students who had been affected by the 2011 Great East Japan Earthquake and consequently evidenced the importance of increasing resilience among affected adolescents. This involved identifying factors contributing to resilience through a model that assessed for each tsunami disaster. This model was determined by assessing the correlation between survivors' resilience scores and their measured psychological and lifestyle scores. This approach showed that, in all tsunami damage models, resilience was most affected by the depressed emotions. Thus, our approach suggests that interventions for improving the depressed mood may improve resilience in adolescents during the COVID-19 pandemic.

Current Trends in the Surgical Management of Intramedullary Tumors: A Multicenter Study of 1,033 Patients by the Neurospinal Society of Japan.

OBJECTIVE: We performed a retrospective observational study to demonstrate the surgical risks and long-term prognoses of intramedullary tumors in Japan using a multicenter registry authorized by the Neurospinal Society of Japan. METHODS: Data from 1,033 consecutive patients with intramedullary tumors, treated between 2009 and 2020, were collected from 58 centers. Patients with spinal lipomas or myxopapillary ependymomas were excluded. Patient characteristics, clinical presentations, imaging characteristics, treatments, and outcomes were analyzed. The modified McCormick scale was used to classify functional status. Survival was described using Kaplan-Meier curves, and multivariable logistic regression analyses were performed. RESULTS: The mean age of the patients was 48.4 years. Data of 361 ependymomas, 196 hemangioblastomas, 168 astrocytic tumors, 160 cavernous malformations, and the remaining 126 cases including subependymomas, metastases, schwannomas, capillary hemangiomas, and intravascular B-cell lymphomas were analyzed. Twenty-two patients were undiagnosed. The mean follow-up duration was 46.1 ± 38.5 months. Gross total tumor removal was achieved in 672 tumors (65.1%). On the modified McCormick scale, 234 patients (22.7%) had worse postoperative grades at the time of discharge. However, neurological status gradually improved. At 6 months postoperatively, 251 (27.5%), 500 (54.9%), and 160 patients (17.6%) had improved, unchanged, and worsened grades, respectively. Preoperative functional status, gross total tumor removal, and histopathological type were significantly associated with mortality and functional outcomes. CONCLUSION: Our findings demonstrate better postoperative functional outcomes in patients with fewer preoperative neurological deficits. Degree of resection, postoperative treatments, and prognoses are closely related to the histology of intramedullary tumors.

Appropriate Health Management Considering the Vulnerability of Women during Disasters.

In situations of a disaster, it has been observed that the damage suffered by women and men is not equal. The vulnerability of women during disasters has been the focus of several studies and disaster management guidelines. Records show that there were more women victims than men victims in both the Great Hanshin-Awaji Earthquake in 1995 and the Great East Japan Earthquake (GEJE) in 2011. Biologically speaking, women are physically less fit than men are; hence, they are more susceptible to physical disabilities induced by disasters and may be disadvantaged in evacuation situations. However, vulnerability of women during disasters is a complex problem that involves physical fitness, as well as other various factors. In the Sendai Framework for Disaster Risk Reduction 2015-2030 (SFDRR) adopted in 2015, prioritized actions such as "Build Back Better" were defined based on the GEJE experiences. In the SFDRR, in addition to vulnerability of women during disasters, medical services including maternal, newborn, and child health and sexual and reproductive health are considered the key factors for disaster risk reduction. This has been discussed in all phases of disaster risk reduction planning and post-disaster response. These findings suggest that the role of obstetrics and gynecology is comprehensive and important as a part of disaster medicine at the local and national levels, as recommended in the SFDRR. In this review, we summarized the management of women's health and gynecological responses during disasters and considered the importance of women as stakeholders in disaster risk reduction.

Co-expression of nuclear heterogeneous nuclear ribonucleic protein K and estrogen receptor α in endometrial cancer.

Heterogeneous nuclear ribonucleic protein K (hnRNPK) regulates the expression of various genes, but has contradictory roles as a tumor promoter and a tumor suppressor. We recently reported that the expression of hnRNPK is negatively associated with malignant behavior of breast cancer where it was induced by estrogen, and bound to estrogen receptor α (ERα) in the nucleus of breast cancer cells. However, the significance of hnRNPK in endometrial cancer, also an estrogen-dependent cancer, remains unclear. In this study, we first examined the localization of hnRNPK and ERα in normal endometrium and endometrial cancer. hnRNPK and ERα immunoreactivity was detected in the nuclei of endometrial glandular and carcinoma cells. In normal endometria, hnRNPK labeling index/immuno-intensity was significantly higher in the proliferative phase than in the secretory phase. In endometrial cancer tissues, hnRNPK labeling index/immuno-intensity was significantly higher in the adjacent non-malignant glandular cells compared to that in carcinoma cells. Immunohistochemistry results for ERα were identical to that of hnRNPK both in normal endometrium and endometrial cancer. In normal and cancerous tissues, the median value of the hnRNPK labeling index was significantly higher in the ERα-high group. Intratumoral estrogen, but not androgen, measured using liquid chromatography-tandem mass spectrometry, was significantly positively correlated with the hnRNPK labeling index in endometrial cancer tissues. Database analysis revealed that the hnRNPK high expression group had a significantly better prognosis for both overall and disease-free survival. These results suggest that hnRNPK interacts with ERα to regulate endometrial changes during the menstrual cycle and suppress the malignant behavior of endometrial cancer.

Dural sac restenosis due to regeneration of the resected C1 lamina in a patient with Chiari malformation: a case report and literature review.

Although foramen magnum decompression (FMD) is effective for the treatment of Chiari malformation type I (CM1), reoperations may be required in cases of insufficient decompression. We encountered a patient who experienced restenosis due to regeneration of resected C1 laminae and required reoperation after FMD.We present the case of a 14-year-old boy with symptomatic CM1 and syringomyelia who underwent FMD with outer dura layer incision and C1 laminectomy. He experienced gait disturbance, hyperesthesia, and hyperhidrosis, which did not improve after the surgery. He experienced recurrence of the stenosis at the age of 16 years, for which he underwent resection of the regenerated C1 arch and duraplasty. His symptoms gradually resolved after the second surgery.The recurrence might have been caused by regeneration of the C1 laminae. Bone regeneration rarely necessitates reoperation. Frequent follow-up is important after decompression surgery for Chiari malformation in young patients.

Identification of the active site and characterization of a novel sporulation-specific cysteine protease YabG from Bacillus subtilis.

In order to characterize the probable protease gene yabG found in the genomes of spore-forming bacteria, Bacillus subtilis yabG was expressed as a 35 kDa His-tagged protein (BsYabG) inEscherichia coli cells. During purification using Ni-affinity chromatography, the 35 kDa protein was degraded via several intermediates to form a 24 kDa protein. Furthermore, it was degraded after an extended incubation period. The effect of protease inhibitors, including certain chemical modification reagents, on the conversion of the 35 kDa protein to the 24 kDa protein was investigated. Reagents reacting with sulphhydryl groups exerted significant effects strongly suggesting that the yabG gene product is a cysteine protease with autolytic activity. Site-directed mutagenesis of the conserved Cys and His residues indicated that Cys218 and His172 are active site residues. No degradation was observed in the C218A/S and H172A mutants. In addition to the chemical modification reagents, benzamidine inhibitedGraphical Abstract the degradation of the 24 kDa protein. Determination of the N-terminal amino acid sequences of the intermediates revealed trypsin-like specificity for YabG protease. Based on the relative positions of His172 and Cys218 and their surrounding sequences, we propose the classification of YabG as a new family of clan CD in the MEROPS peptidase database.

Evaluation of the nutrient foramen as a suitable landmark in spinal surgery.

BACKGROUND CONTEXT: The posterior cervical approach is a very popular surgical procedure. Because of the slope-shaped laminae, a suitable landmark for laminectomy, laminoplasty, and pedicle screw placement does not exist. PURPOSE: We investigated the association between the nutrient foramen and spinal canal, and the safety of bone gutter placement using nutrient foramina for safe and effective spinal surgery. STUDY DESIGN: Observational SETTING: University Hospital PATIENT SAMPLES: Two hundred and sixty-six consecutive patients treated for cervical pathologies in our university hospital between January 2005 and December 2019. OUTCOME MEASURES: We identified the location of nutrient foramina and their anatomical association with the spinal canal using preoperative three-dimensional CT scanning. METHODS: We studied the distance between each foramen and the spinal canal, and the angle of the nutrient foramen at each vertebral level. RESULTS: The nutrient foramina were always located outside the spinal canal, with an average distance of +3.06±1.74 mm. The lower the spinal level, the closer the nutrient foramen to the spinal canal. CONCLUSIONS: The nutrient foramen can be considered a reliable landmark when using the posterior cervical approach.

[Anterior Cervical Discectomy and Fusion:Safe Surgical Operation Based on Detailed Anatomical Knowledge].

Anterior cervical discectomy and fusion(ACDF)was developed by R.B. Cloward in the 1950s and it has spread over the world for the treatment of the spinal degenerative disorders. It is considered to be the most effective treatment for patients with anterior compression of the spinal cord. Because most of the surgical complications reportedly occur while approaching the vertebral column through the subcutaneous tissues, precise knowledge of the topographic anatomy of the neck is crucial for effective and safe surgery. In this paper, we describe the appropriate surgical maneuvers in each surgical step, based on anatomical knowledge, for avoiding surgery-related complications. We would like to emphasize that anatomical features differ with individual patients; therefore, careful preoperative evaluation is very important. Surgical strategy, based on adequate preoperative evaluation, will lead to good postoperative results.

Correlations Among Consistency, Computed Tomography Values, and Histopathological Subtypes of Spinal Meningioma.

The consistency of spinal meningiomas is important to consider when performing tumor removal surgery. This study evaluated the correlations between spinal meningioma consistency and both preoperative computed tomography (CT) values and histopathological subtypes. Fifteen consecutive patients who underwent surgical resection of spinal meningioma at our institution were identified, and preoperative CT values and the signal intensity of T2-weighted magnetic resonance images of the tumor were determined retrospectively. The consistency of the spinal meningioma was defined based on the ultrasonic surgical aspirator output during tumor debulking. Patients were assigned to 2 groups: a soft group (n=4) and a hard group (n=11). The T2 signal intensity was significantly higher in the soft group than in the hard group (p=0.001). While the CT values were considerably higher in the hard group, the difference was not significant (p=0.19). Regarding the histopathological subtypes, psammomatous meningioma exhibited significantly higher CT values than meningothelial meningioma (p=0.019); however, there was a higher frequency of hard tumors in meningothelial meningioma cases than in psammomatous meningioma cases. Although neither robust correlations between tumor consistency and CT values nor a relationship between tumor consistency and histopathological subtype has been established, these results might help with the perioperative manegement of spinal tumors.

Association of subjective health and abnormal cervical cytology in Japanese pregnant women: An adjunct study of the Japan Environment and Children's Study.

This study examines the association between abnormal cervical cytology and subjective health in pregnant women, as an adjunct to the Japan Environment and Children's Study, which cross-sectionally analyzed a subset of the prospective cohort. A total of 3024 pregnant women at a childbirth facility whose medical records of cervical cytology in the first trimester of pregnancy were transcribed and who responded to the subjective health questionnaire were included herein. They were classified into excellent, good, fair, and poor groups based on their subjective health. Cervical cytology results obtained from perinatal medical records were classified into normal and abnormal cytology based on the Bethesda classification. Logistic regression analysis adjusted for baseline characteristics, including age, pre-pregnancy body mass index, parity, and other possible confounding factors, was used. Of 3024 pregnant women, 106 (3.5%) had abnormal cytology, with the prevalence being 1.3%, 3.7%, 3.9%, and 4.0%, respectively (p = 0.055) in the poor, fair, good, and excellent groups. The baseline characteristics, namely age, history of gynecological diseases, Kessler 6-item psychological distress scale score, and history of mental illness, were significantly different between groups. Compared to the poor group, the other three groups had a significantly higher abnormal cytology risk after adjusting for confounding factors (Fair: adjusted OR [aOR] = 3.6, 95% CI [1.0-12.1]; Good: aOR = 4.6 [1.3-15.5]; Excellent: aOR = 4.6 [1.2-17.8]). This study encourages young women to undergo cervical cancer screening because they are at risk for cervical cancer even if they think that they are healthy, and preventive activities like regular screening are essential.

Tailor-Made Endoscopic Surgical Strategy for Severe Intraventricular Hemorrhage with Obstructive Hydrocephalus.

BACKGROUND: Severe intraventricular hemorrhage (IVH) is associated with a high mortality rate and poor functional outcome, even with recent neurosurgical developments. IVH requires emergent surgery to save the patient's life, but the optimal surgical strategy remains controversial. We assessed the results obtained with our tailor-made endoscopic surgical strategy for severe IVH with obstructive hydrocephalus. METHODS: Consecutive patients with severe IVH owing to intracerebral hemorrhage who were treated with endoscopic surgery in the acute phase were retrospectively reviewed. Both rigid and flexible endoscopes were used for removal of hematoma in the whole ventricular system. Endoscopic third ventriculostomy and septostomy were performed as appropriate in each individual case. RESULTS: Eight patients met the inclusion criteria and were included in the analysis. Sufficient IVH removal without neglecting the fourth ventricle was achieved with our technique in 6 of 8 cases (75.0%). Endoscopic third ventriculostomy and septostomy were added in 4 cases each (50.0%). Four patients (50.0%) had a marked recovery and a good outcome (modified Rankin Scale score ≤2) despite disease severity at onset. The procedure was completed successfully in all cases, and there were no surgery-related complications. CONCLUSIONS: This study showed that our tailor-made endoscopic surgical strategy for severe IVH with obstructive hydrocephalus may be beneficial.

Mental Health and Physical Activity among Children and Adolescents during the COVID-19 Pandemic.

Coronavirus disease 2019 (COVID-19) is causing disruptions in the global social system. Japanese children and adolescents have had their schools closed, government-mandated activity restrictions imposed, and interactions outside the home reduced. These restrictions can have a considerable psychological impact on children and adolescents. This review aims to describe the impacts of COVID-19 pandemic on physical activity and psychological status of this population. The review was conducted by searching PubMed for information on the impact of COVID-19-related activity restrictions on children and adolescents. The search identified 11 articles, three of which contained data on anxiety and psychological problems due to physical inactivity. Next, a PubMed search was conducted about physical activity and psychological status in children and adolescents under psychological stress. The search identified 368 articles, 28 of which were included in the review. For children, data that revealed a correlation between physical activity and psychological health and sedentary time leading to mood disorders were included. For adolescents, there were nine studies that reported a correlation between physical activity and psychological health and four studies that reported no correlation between physical activity and psychological health. Of the studies that reported a correlation, seven reported that physical activity improves psychological health. The impact of psychologically stressful situations such as COVID-19 on children and adolescents has been experienced worldwide. Physical activity has been correlated with psychological health, and it may improve psychological status; physical activity should be recommended to better support the psychological health of children and adolescents under the influence of COVID-19.

The first-round results of a population-based cohort study of HPV testing in Japanese cervical cancer screening: baseline characteristics, screening results, and referral rate.

OBJECTIVE: In 2013, a cohort study aimed to clarify the positive and negative effects of introducing the human papillomavirus (HPV) testing for population-based cervical cancer screening has been launched in Japan. This study included four screenings during the subsequent 7-year follow-up period. We aim to describe the results of the first round of this study on cervical cancer screening here. METHODS: This study began in September 2013 with recruitment completed in March 2016. Women aged 30-49 years were divided into 2 groups: those who received uterine cervical cytology alone in the first year (control group), or those who received a combination of cytology and HPV testing (intervention group), based on their age. After first screening, women with positive result of cytology or positive HPV test required referral. We summarized the results of the first round of cervical cancer screening. RESULTS: Of the 25,074 women who were eligible for the study, 13,845 women (55.2%) were screened with cytology alone; 11,229 women (44.8%) received a combination of cytology and HPV testing. After screening, 407 women (2.9%) in the control group and 1,003 women (8.9%) in the intervention group required referral, respectively. Adding HPV testing increased referral rate significantly (p<0.001). CONCLUSION: After first screening, introduction of HPV testing appears to contribute to significantly higher referral rates, suggesting that the number of colposcopies as a detailed examination may increase. These preliminary findings suggest that if HPV testing is introduced into screening, medical institutions need to be prepared for an increasing number of follow-up examinations.